BUREAU OF CODE ENFORCEMENT
CITY OF SCHENECTADY
NEW YORK
City Hall
105 Jay St., Room 17
Schenectady, NY 12305
Tele: (518) 382-5050
Fax: (518) 372-9459
Date: ________________________
PERMIT ACCEPTANCE CHECK LIST
FROM HOMEOWNER (OWNER OCCUPIED)
x
_____________________PERMIT APPLICATION
x
_____________HOMEOWNER WAIVER
x
_____________ELECTRICIAL PERMIT REQUIRED
x
_____________PLUMBING PERMIT REQUIRED
x
_____________HOMEOWNER HAS QUESTIONS – REQUESTS CODE OFFICER CALL HOMEOWNER
__________________________________________
Homeowner Signature
Building Permit Drop-off Hours:
September - June
Monday thru Friday
______________________________________
Contractor Signature
8:00 am – 5:00 pm
July & August
Monday thru Friday
______________________________________
Code Enforcement Officer Signature
8:00 am – 4:00 pm
Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
**This form cannot be used to waive the workers’ compensation rights or obligations of any party**
Under penalty of perjury, I certify that I am the owner of the 1,2,3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to
show specific proof of workers’ compensation insurance coverage for such residence because
(please check the appropriate box):
I am performing all the work for which the building permit was issued.
I am not hiring, paying or compensating in any way, the individual(s) that is (are) performing all
the work for which the building permit was issued or helping me perform such work.
I have a homeowner’s insurance policy that is currently in effect and covers the property listed
on the attached building permit AND am hiring or paying individuals a total of less than
40 hours per week (aggregate hours for all paid individuals on the jobsite) for which the
Building permit was issued.
I also agree to either:
™ Acquire appropriate workers’ compensation coverage and provide appropriate proof of that coverage
on forms approved by the Chair of the NYS Workers’ Compensation Board of the government entity
issuing the building permit if I need to hire or pay individuals a total of 40 hours or more per week
(aggregate hours for all paid individuals on the jobsite) for work indicated on the building permit,
or if appropriate, file a CE-200 exemption form; OR
™ Have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, provide appropriate proof of
workers’ compensation coverage or proof of exemption from that coverage on the forms approved by the
Chair of the NYS workers’ Compensation Board to the Government entity issuing the building permit if the
project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for
work indicated on the building permit.
_______________________
_____
(Date Signed)
________________________________________
(Homeowner Signature)
Home Phone Number_____________________________________
_________________________________________
(Homeowner’s Name Printed)
Property address that requires the building permit:
Sworn to before me this _______________ day
____________________________, ____________________.
__________________________________________________________
__________________________________________________________
_________________________________________________
(County Clerk or Notary Public)
__________________________________________________________
Once notarized, this BP-1 form serves as an exemption for both workers’ compensation and disability benefits insurance coverage.
CITY OF SCHENECTADY
BUILDING PERMIT APPLICATION
LOCATION OF BUILDING
DATE ___/___/___
NUMBER and STREET__________________________________________________________________
OWNER
CONTRACTOR
DESIGNER
Construction Debris Plan
_______________________________
NAME
_______________________________
ADDRESS
_______________________________
NO P. O. BOXES
PLEASE
_______________________________
ZIP CODE
_______________________________
(All debris must be removed within
24 hours of completion of work)
TELEPHONE
NUMBER
OFFICE USE ONLY
SWO
YES
NO
Describe in detail proposed work and use:
TOTAL COST OF JOB
(OMIT CENTS)
$
PERMIT FEE
FOR OFFICE USE ONLY:
 Footing  Foundation  Backfill  Framing  Insulation  Final
$
WORK COVERED BY THIS BUILDING PERMIT MUST BEGIN WITHIN THIRTY (30) DAYS OF THE EFFECTIVE DATE OF THIS
PERMIT AND MUST BE COMPLETED WITHIN ONE (1) YEAR OF THE EFFECTIVE DATE OF THIS PERMIT UNLESS EXTENDED IN
WRITING BY THE BUREAU OF CODE ENFORCEMENT.
TYPE OF WORK
NEW
ADDITION - ENTER UNITS ADDED
ALTERATION - ENTER NUMBER OF
UNITS ________
DEMOLITION
CHANGE OF OCCUPANCY
SELECTED CHARACTERISTICS OF BUILDING
RESIDENTIAL
ONE FAMILY
A ASSEMBLY
TWO OR MORE FAMILY
ENTER NUMBER OF UNITS ______
HEIGHT IN STORIES
TRANSIENT HOTEL, ETC.
ENTER NUMBER OF UNITS _____
GARAGE
NON-RESIDENTIAL
S STORAGE
B BUSINESS
I INSTITUTIONAL
M MERCANTILE
U UTILITY/MISCELLANEOUS
F INDUSTRIAL
OTHER (Specify)
REPAIR/REPLACE /IMPROVE
PRINCIPAL TYPE OF FRAME
MASONRY
STEEL
FRAME
CONCRETE
OTHER (Specify)
OTHER (Specify)
ADDITIONAL PERMITS SHALL BE
OBTAINED
PRINCIPAL TYPE OF HEAT
□ GAS
□ OIL
ELECTRIC
□
ELECTRICAL
□
PLUMBING
□
OTHER (Specify)
C CURB/SIDEWALK
SEWER
IN SIGNING THIS PERMIT APPLICATION, THE UNDERSIGNED APPLICANT CERTIFIES THAT ALL INFORMATION PROVIDED
ABOVE IS TRUE AND ACCURATE AND THAT THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO COMPLY
WITH ALL APPLICABLE LAWS OF THE CITY OF SCHENECTADY.
___________________________________________
Applicant Signature
__________________________________________
Applicant Address
___________________________________________
Applicant Name (Please print)
__________________________________________
Officer Signature